Tag Archives: Intake

Evaluating Interpersonal Dynamics in the Initial Clinical Interview

As we begin the revision process for Clinical Interviewing, I’m discovering content here and there that I want to share. Below is a short excerpt from the Intake Interviewing chapter where we’re discussing the process of evaluating clients’ interpersonal behavior patterns. Please email me your reactions and recommendations if you have some.

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Evaluating Interpersonal Behavior

Interpersonal behavior is central in the development and maintenance of client problems. Some theorists claim that all client problems have their roots in relationship problems (Glasser, 1998). Evaluating client interpersonal behavior is an essential part of an intake interview.

Intake interviewers have five potential data sources pertaining to client interpersonal behavior.

  1. Client self-report. This includes self-report of (a) past relationship interactions (e.g., childhood) and (b) contemporary relationship interactions.
  2. Clinician observations of client interpersonal behavior during the interview.
  3. Formal psychological assessment data.
  4. Information from past psychological records/reports.
  5. Information from collateral informants.

Although some behaviorists and in-home family therapists also observe clients outside the office (e.g., in school, home, and work environments), it’s unusual to have those data available prior to an intake.

Evaluating interpersonal behavior is difficult. Each of the preceding data sources can be suspect. For example, client self-report may be distorted or biased; often clients cast their interpersonal behaviors in a favorable light, or they may excessively blame themselves for negative interpersonal experiences. Clinician observations are also subjective. When you’re evaluating client interpersonal behavior, it’s wise to use several basic assessment principles to temper your conclusions:

  1. Single observations are often unreliable. This is partly because interpersonal behavior can shift dramatically from situation to situation. Multiple observations of behavior patterns (e.g., interpersonal aggression or interpersonal isolation) are more reliable.
  2. Just as construct validity is established through multimethod, multitrait assessments (Campbell & Fiske, 1959), interpersonal assessments are more valid when you have converging data from more than one source (e.g., self-report plus clinician observation).
  3. The literature is replete with theory-based models for interpersonal assessment. When clinicians hold strong theoretical beliefs, confirmation bias is more likely (in other words, you will make observations that confirm your theoretical stance or hypothesis). Therefore, you should regularly question conclusions about client interpersonal behavior based on your preexisting ideas.

One of the most popular models for conceptualizing interpersonal behavior is attachment theory. Adherents to this perspective believe that early caregiver-child relationship interactions create internal working models about how relationships work. Essentially, this leaves clients with consistent (and sometimes rigid) interpersonal expectations and reactions. For example, clients with insecure attachment styles may expect or anticipate rejection or abandonment, while clients with ambivalent attachment styles alternate between pushing others away and clinging to them. Typically, maladaptive components of client internal working models are activated during the early stages of new relationships or during times of significant stress, when support and reassurance are needed (O’Shea, Spence, & Donovan, 2014).

Interpersonal assessment based on attachment theory is a psychodynamic approach and involves a depth-oriented assessment process. However, the idea that individuals have internal working models that guide their interpersonal behaviors is consistent across many different theoretical perspectives. Specifically,

  • Cognitive therapists emphasize client schema or schemata that shape what clients expect in interpersonal relationships (Young, Klosko, & Weishaar, 2003).
  • Adlerian therapists use the term lifestyle assessment to refer to the evaluation of client expectations about the self, the world, and others (Carlson, Watts, & Maniacci, 2006).
  • Psychoanalytic therapists refer to the client’s core conflictual relational theme (CCRT) as a target for treatment (Luborsky, 1984).
  • The whole emphasis of the empirically supported interpersonal psychotherapy for depression is based on addressing problematic interpersonal relationship dynamics (Markowitz & Weissman, 2012).

It’s always advisable to attend to feelings and reactions that clients elicit in you (Teyber & McClure, 2011). For example, some clients may trigger boredom, arousal, sadness, or annoyance. These personal and emotional reactions can be viewed as countertransference (Luborsky & Barrett, 2006). However, if there’s convergent evidence that reactions the client is evoking in you are also evoked in others, it’s likely that the client’s interpersonal behavior is the culprit. If your reactions are unique, then your countertransference reaction may be more about you and less about the client.

Evaluating a client’s personal history and interpersonal behaviors is a formidable task that could easily take several sessions. Expecting that you should have a precise sense of your client’s interpersonal style after a single interview is unrealistic. A better goal is to have a few working hypotheses about your client’s interpersonal behavior patterns (see Case Example 8.2).

CASE EXAMPLE 8.2: DESCRIBING INTERPERSONAL OBSERVATIONS

The following intake note focuses on interpersonal observations and, consistent with a collaborative/therapeutic assessment model, uses a descriptive rather than a labeling approach.

Miriam, a 36-year-old White, married female, described herself as suffering from tension and stress in her marital relationship. She reported, “My husband always calls me controlling, and I hate that, but sometimes he’s right.” During our session, Miriam repeatedly (about five times) asked for more information, complaining that she “really needed” to understand exactly what counseling was about before she could be sure she wanted to proceed. As we discussed her husband’s comments in greater detail, Miriam noted that she believed her “need for control” was related to anxiety. Together we identified several triggers that elicit anxiety and are then followed by self-identified controlling behaviors. These comprised (a) new situations (like counseling), (b) her husband leaving the house without telling her his plans, and (c) when she feels neglected by her husband. Overall, these triggers may be related to an internal working model where Miriam’s sense of relational security is threatened. Consequently, one of our first therapy tasks is for Miriam to engage in a self-monitoring homework assignment to help further refine our understanding of the interpersonal triggers that activate her “controlling” behaviors.